605 Title 5 Inspection 2003 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
G.s X/04.-';7/ ti/4J6 57. g p J
Property Address:
7.202,Erhrrridnyx /1d/5Z-55
Owner's Name: i✓CJi2 Vlc21— (Welt a=•.
Ownec's Address: 7_�3ry C.r/.c/'/{ ,900re/
A-i2r/rA' rz.2w/ ,1.-t•9 s 5
Date of Inspection: Aiout A'C 50C%�'' ` '.
Name of Inspector:(please print) - L/1 ry
/c.ti Al 1,14.14/ ./
Company Name: 4/ / (/r}} A:Act
XO/
Mailing Address:
Telephone Number:
r
T f
_lets``�
SeG=
CERTIFICATION STATEMENT -sa..S
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper fitnction and maintenance of on site sewage disposalsystems.lama DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system.
Passes
Conditionally Passes
NA ds Furth. Eval - ion by the Local Approving Authority
Inspector's Signature:
Date:
&'/20o3
The system inspector shall submit•copy of this inspection report to the Approving Authority(Board of health or
DEP)within 30 days of completing this inspection.If the system is a shared system or bas a design flow of 10,000
gpd or greaten,the inspector and the system owner shell submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority. //
Notes and Comments C.-�J,k 7 4- Ot-0 G
$(�f P h'J
/-coo tee? e:4il7yr 5j5Z" ' 15
***Mils report only describes conditions at the time of Inspection and under the conditions of use at that
time.This Inspection does not address how the system will perform in the future under the same or different
conditions of use.
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT&
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE(TION'FORM
PART A
.n CERTIFICATION(mstmrd)
4r4
Properly Address: '0/4)* 08,14/Q, s
a m
Owner. . S l L-
a 2-42/Zc03
Inspection Sammaryr Cheek A,B,C,D or E/ALWAYS complete&I of Section D
A. Sjstt Passes:
I newt found any information which' •'—Ns that any of the failure&Rtetia described in 310 CMR
15.303 or In 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below.
Date of Inspection:
Coaenb:
5trk, G(JOr/c,A - roms , it'
B. System Conditionally Perm:
_ One or more system components as described in the."Conditional Pass"section need to be replaced or
repairtd.The system,upon Completion of the replacement or repair,au approved by the Board of Health,will pass.
Answer yes,no ante determined(Y,N,ND)in the for the following stafine"tc If'loot determined"please
explain.
_The septic tank Is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial hnfltrWen or exflbation or tank hikes is(mmloeat.System will pam inspection lithe
existing tank is replaced with a complying septic tank as approved by the Bored of Health.
cA meet septic tank will pass hupeaion if it is structurally sound,not leaking and ifa Certificate o&Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Obwvation ofsewage backup or break oat at high state net level a the dhmimtiiou box duet:Aral=or
obstructed pipe(.)of due to a broken,settled ormevea datribrmionbox.S)WIn win pass inspection if(with
approval of Board of Health):
broken obimic ienmoad
_ dlatribtdl a box is leveled sr emplaced
NDexpkWin:
_ The system required pumping more than 4 taken a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board°Meld)
broken pipe(s)are replaced
obstruction is removed
,Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: j ..0 /79/PA/S/'
OA.., w!/9
Owner: /1/ .SeN UCrE�
Date of Inspection: ///,E/O3
C. Further Evaluation is Required by the Beard of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a saltnarsh
2. System will fail unless the Board of Health(and-Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the pablie health,safety and environment:
4.
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
otos /-.ni ,taa,tc Si
Nana'zy's nycyc t,
tie .rtNU4_7z
l'/ari/a3
D. System Failure Criteria applicable to all systems:
You wig indicate"yes"or"110"to each of the following for all inspections:
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
- 1L/Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
P,Wt LL�,quid depth in cesspool is less than 6"below invert or available volume is less than''day flow
Required pumping more than 4 times in the last yearsNOT due to clogged or obstructed pipe(s).Number
„Al times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_t,e/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
Avater supply.
— ✓ My portion of a cesspool or privy is within a Zone I of a public well.
_ y portion of a cesspool or privy is within 50 feet of a private water supply well.
ty portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. l'his system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from poliut ntfrom that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to r less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form./
/4 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 3*MR 15.303,therefore the system fails.The system owner should contact the Board of
Health to detemiin 'what will be necessary to correct the failure.
E. Large Systems: 1/41%9
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
SPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section 1)above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 60X 449,17 7,,e-i rp ;% ,
Owner: Al
Date of Inspection: // t (ot)
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two eeks?
H- as the system received normal flows in the previous two week period? '-
Have large volumes of water been introduced to the system recently or as part of this inspection?
./ Were as built plans of the system obtained and examined?(Ifthey were not available note as N/A)
/QC r.vv4/t,4t;tL
it Was the facility or dwelling inspected for signs of sewage back up
1.7 Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
W- ere the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health. 0 Z-0 /Ud e.02'.0 5
Dvwa
V D- etermined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
•
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART C
SYSTEM INFORMATION
Property Address: ePa`S/inn't
Owner: ,S CCfUL n'
Date of Inspection:
CONDITIONS
RESIDENTIAL 2,v/9
Number of bedrooms(design):_ Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd z#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):_
Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_ -
Water meter readings, if available(last 2-years usage(gpd)):
Sump pump(yes or no):_
Last date of occupancy:
COMMERCIALQNDUSTRIAL on -' c f//,e IL/L/ . //Z £
Type of establishment: :
Design flow(based on3l0CMR15.203): /PO and ua' 30 rja-QS/v/g tY
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):!A/O
Industrial waste holding tank present(yes or no): /L10 / �
Non-sanitary waste discharged to the Title 5 syj�(yes or no): ,J(O
Water meter readings,if available: pit/!L 6/x.a
Last date of occupancy/use: QyELJ
/3
OTHER(describe):
Pumping Records
Source of information: .,o U!I(J/i/e /v ac11dOG71.
Was system pumped as part ofthLe inspection(yes or no): A/o
If yes,volume pumped:ngillens—How was quantity pumped determined?
Reason for pumping. Apr"OU/Y//p eel ,4v /// /O/a7,Apc/
TY$E OF SYSTEM /N G11$T th-r'o (,c//WE4 Z✓C,.JO
mif/
V Septic tank,distribution /oi!779/
box,soil absorption
system Z G8/K/fly f.iC-Ga'7S
_single cesspool z .p/ sr /j O.t'
_Overflow cesspool
ivy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(descnbe): Two a-.PUwit-6 /°/,_l.,OS y ,Q/,j% ,4O-t.C-S'
Approximate age of all components,date installed(if known)and source of information: 30 f
its G c/V
GENERAL INFORMATION
,,(X! 5z cs`Cerf
z �j.9Y /2D0/ti7
! �//7�✓%P -ems
ea /rape/.r /ace c)/-5'
A9 4q� .
eSao F! z
/5ZO FTC
Were sewage odors detected when arriving at the site(yes or no): ,(f(2
Page 7 of I1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46S 4.)0/07", /),41/4../$%
'CAD/Gf- i9/✓I,w6-0, ) Ain
Owner: Al' . f s. -ot rE
Date of Inspection: ///4 OA?
BUILDING SEWER(locate on site plan)
Depth below grade:
3c' "
Materials ofconstructiot iron 40 PVC other(explain):
Distance from private water supply well or suction line: !%U/J/tc //t O
Comments(on condition ofjobits,venting,evidence of leakage,¢tcj:
/At. y, ,n �,t,ae T?il y CO/V.O/ 774 U
SEPTIC TANK:_(locate on site plan)
"
grade:below ade: �7
Material of constructionLg of constructioth„Veoncrete_metal_fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) n
Dimensions: �O C S Y S Ye F/Oku /, -s /000 OAte- 27)14-
Sludge depth: (0 r
Distance from top of sludge to bottom of outlet tee or baffle: A.YL</ /g 4,FzS
Scum thickness: / 3
Distance from top of scum to top of outlet tee or baffle: s. n/,��/�P�
Distance from bottom of scum to bottom of outlet tee or baffle: / Al Pas% e//t/ '
How were dimensions determined: /j4..?I'Z, 5L'%v/c /VC
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence ofleakape etc.):
. )49'/CJ%l' /v e€o I Aiet/ /-P-Cy y pvc lee
/9.0 /7-3-0e 214'9
GREASE TRAP:_(locate on site plan)Qk(J/j
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page g of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ,000,771
nit/ Gcle)
Owner: ,C'G/tt 0 1
Date of Inspection: //`o7°/OS
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete_metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons _
Design Flow: gallons/day
Alarm pretest(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: 2- Of present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
of
Comments(note if box is level and distribution to oudgtsequal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
z U X s
Ai s r /5
YW/cJ _C720AQCo ,p Li
L�3c7Act-S.
2 £Pp<!ra & oi1G/, /w, f'SCts. r5
PUMP CHAMBER: (locate on site plan) 1 4_
Pumps in working order(yes orno):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
405" Lido 7,' /z9/y eat s'T
Owner: /t% �'CNOc7E
Date of Inspection: /W 40/613
Property Address:
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: '
leaching chambers,number:_
leaching galleries,number.
leaching trenches,number,length:
�( leaching fields,number,dimensions:
_overflow cesspool,number:
innovative/alternative system Type/name
F/ tze ,, li/f/L PS
Cts�At) 6frrO(-. - x
/OP' C /0 _-/o.
Z S
.5Z) fre_o• 6 a- /G
5
of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): /SDO`r
70J
t
it/r9
CESSPOOLS:_(cesspool must be pumped as part of inspectionXlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver: 'c'
Dimensions of cesspool: ,
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_(locate on site plan
)4911/A
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
O5—
Property Address:
4/0/2.77-71 /r/li/.cJ 5 7 c a1
,CJO.€J`///7/ry/9/CaJ P -IAI
Owner: N' SC MOL /
Date of Inspection: // Bl o p3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
ging ,a
/P,-ap t. e
z_,c/9-C- Lt. co c
D
EPfij2
Y L /6.4 o 0 9�
\. t \ Se//�c /mow/
( ye 00 /=/
Kyp4�,�
77-6/2.46
ll s
f 6Y.k/J /9/v2 t/s(/G "me,
,/o/L,77/ /c//Uo ST
zCOU
18 00
/ N
7 (o & Crzi,rfi
- Page 11 of I1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Gas Aidoe'25' 0347 41.57
A/OrimAmp a/ wI/9
Owner. ,LJ.- SC!✓r/L
Date of Inspection: /03
SITE EXAM
Slope 0
Surface water ,l/G It P
Check cellar 5'O' 4 CO R/si'X4--G TZ r.
Shallow wells
to
Estimated depth to ground water r feet 40C f�� ® ./...)../24„. a f
Please indicate(check)all methods used-to determine the high ground water elevation:2P/P C
Obtained from system design plans on record-If checked,date of design plan reviewed:
t/Observed site(abutting property/observation hole within I50 feet of SAS)
Checked with local Board of Health-explain:
t/Checkedwith local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
/00 S/C0 {mss a .rer`j/<o // Ne o /P//Ge CP° --r
70 AI/6 71 a 4V
,EST N iuJ r Le/G u/ /o'0 "